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Adult 2 Exam 2
CARDIOVASCULAR DISEASE
Leading cause of death for males & females, regardless of race
- Cardiac cycle: Systole & Diastole
- Systole is Ventricular Contraction
- Diastole is Ventricular Relaxation
- CO: How much blood is ejected every minute (CO=SV x HR)
- SV: How much blood is pumped w/ each contraction
- Preload: How much muscle is stretched after Diastole
- Afterload: The resistance the Ventricle is ejecting against
EKG
- During procedure, lie still for 5-10 seconds
- Nurses & Respiratory Therapists can do EKGs
Parts of an EKG-
o Horizontal Axis: The time that goes by (each box is 0.04 sec)
o Vertical Axis: Amplitude/voltage
o P wave: Atrial Depolarization, not atrial contraction bc this is the electrical activity telling the atria to contract
o QRS: Ventricular Depolarization/Atrial Repolarization (hidden)
o T: Ventricular Repolarization
o U Wave: Purkinje Fibers Repolarization (could be pathological)
SINUS RHYTHMS
Sinus Rhythm means the SA node is generating your impulse (the pacemaker)
ST DEPRESSION: with low K or if they are on Digoxin
Reading a Normal EKG
- Normal HR is 60-100 (normal sinus rhythm)
- Rhythm: R to R distance should match up
along strips (regular rhythm)
- P should be in front of every QRS
- QRS & T should be pointing same direction
ATRIAL FIBRILATION
- Uncoordinated Atrial Activity
- Atriums are just twitching
- Not pushing blood into the ventricle like they are supposed to
- No Pattern- R to R distance doesn’t match so rhythm is
IRREGULAR
- You can’t identify the P
- Beta Blockers are given to control HR
- Anti-Coagulant (Coumadin) bc they are at a high risk for clots
ATRIAL FLUTTER
- “Saw Tooth Wave” between R-R
- No distinguishable P wave
A Fib is faster & more chaotic than A Flutter
STEMI :
“ST elevation MI”
- Probably means they are having a heart attack
- Could be from high K levels
Angina Pectoris
- Stable Angina is relieved by Rest or Nitro
- Unstable Angina is not relieved by rest or nitro &
considered MI w/ STEMI or non-STEMI
Medications for Angina
Nitroglycerin
Vasodilator / ¯ Preload & Afterload
- Side Effects: ¯BP, Headache
- Types:
o Sublingual: every 5 min up to 3x
o Patch
§ Write date/time/initial
§ Chart which arm or chest
§ Tell pts they can shower/swim
§ Put on in am, take off pm (tolerance)
§ Prevents CP but does not stop an attack
o Assess BP
o Ask if they are on Viagara
(both vasodilate, so BP will drop quick)
Used if they have had Angina in the past
Beta-blocker
(Metoprolol/Carvedilol)
¯ HR and BP
- DONT stop abruptly- Rebound HTN
- DM- masks Hypoglycemia symptoms
o Monitor BG often
- Don’t use w/ Severe Asthma or COPD
o It can cause bronchoconstriction
o Wheezing or SOB-- call provider
and switch medications
Ca Channel Blocker
(Amlodipine/Diltiazem/Verapamil)
BP - check before giving
o at risk for vasospasms
& this med helps that
Heparin
Anticoagulant
Prevent DVT or Clots
• SUBQ
o Needle: 5/8 & 25-30G
o Therapeutic is 45 - 75
o Normal is 30
Protamine Sulfat
o ¯ BP/¯ H&H/ HR
- Heparin Induced Thrombocytopenia
o Hold Pressure Longer
o Avoid IM Injection
o Avoid Continuous BP Cuff
Enoxaparin (Lovenox)
Must give air bubble to pt bc it
seals the medication inside
tissue
ASA (Aspirin)
¯ Platelet Aggregation
¯ Risk for Clots
- Dose: 81 mg
- Side Effects:
o GI Bleeding/GI Upset
- Ask if they have taken Aspirin that day so you
don’t give them too much
Oxygen
(considered a medication)
- Give O2 for CP
- 2L Nasal Cannula & then
Call Physician
o N/V
o Coughing
o Nasal Stuffiness
o Sub-sternal Pain
Assessment
- ECG: 12 lead
- Lab: Cardiac Enzyme- 3 sets, every 6 hrs to see trends
o Troponin and CK-MB
- Chest X-ray: CP can come from Pulmonary origin so this
is to rule out different things
o No metal, Check for pregnancy
Signs & Symptoms
- Chest pain is a Heavy Sensation
o “Elephant sitting on chest”
- Pain is usually behind Sternum
o Can radiate to Neck, Jaw, Shoulder or Right Arm
- May tell you they have Indigestion & Choking Sensation
- DM-- may not feel Chest Pain due to Neuropathy
- Women & Elderly-- may just have SOB & Weakness or Silent
- May occur upon:
o Physical Exertion
o Eating Heavy Meal
o Stress or Cold Environment bc Vasoconstriction
Nursing Process: Angina
Assessment : COLDSPA – what were they
doing, activity level, risk factors,
understanding of CP
Physical – vitals, heart, lung, abdomen,
peripheral vascular (pulses and edema)
Interventions: Place pt in Semi-fowlers,
rest; assess O2 & vitals, EKG and labs;
teach stress reduction and prevent pain;
stop smoking, watch activity level, carry
nitro all the time, follow up appts
Diagnosis: Ineffective tissue perfusion r/t
decreased coronary blood flow aeb pt
reports chest pain; ABCs, deficient
knowledge
Planning/Goals: reserve heart muscles &
treat signs and symptoms
Cardiac Stress Testing
Goal is 80 - 90% of max HR-- Max HR = ( 220 – Age)
Exercise Stress Test: run on treadmill/pedal
bicycle or arm crank; test takes 1-3 hrs
Pharm Test: Vasodilators (Dabutamine, adenosine)
o Side Effects: Flushing/Nausea/HA/Dizziness
- Avoid tobacco, caffeine, and alcohol before
Nursing Interventions
- Instruct pt to fast 4hr before test
- Can take meds w sips of water
- Avoid intense exercise 3 hrs before
- Signed consent needed
- Dr may say not to take meds (beta blockers)
- IV Site just in case they have MI during test
Symptoms to Report
CP, dyspnea, dizziness, leg cramp, fatigue
change in EKG, BP or HR change, pallor, sweat
- All indicates (+) EKG—STOP THE TEST
- Pt needs treatment in cardiac cath
Post-Test: avoid hot bath/shower for 1-2 hrs
MIBI
Technetium-99m labeled methoxy-
isobutyl-isonitrile
Test Perfusion in Heart
IV injection of Radioactive Isotope-
not a concern bc lose radioactivity
after a few hrs
- NO caffeine 12hrs before
- Don’t smoke 2 hrs before
- No food 2 hrs before
- Lie on back w/ arms
extended over head
- Camera is taking pics
- Test will take 2-3 hrs
- Fatigue after is normal
Myocardial Infarction
- Acute Coronary Syndrome, includes Unstable Angina/nonSTEMI/and STEMI
- In an MI, areas of the Myocardium are permanently destroyed resulting in death of Myocardium
- Profound imbalance between O2 Supply & Demand
- Assessment
- Chest Pain – continues w/ Rest & Nitro
- Dyspnea, Indigestion, Nausea, Anxiety
- Diagnostic: Cardiac Enzymes & Biomarkers (Troponin, CK-MB)
- ECG within 10 minutes
- Goals of Med therapy: Prevent tissue death and prevent complications
Drug Therapy
(MONA – Morphine, Oxygen, Nitro, Aspirin)
- if 3 Nitros don’t work, call Physician & get an order for Morphine IV Push
- Cardiac rehab: try to return to pre-illness lifestyle/work; teaching, counseling, interdisciplinary team
Nitroglycerin
Vasodilator
Morphine
Analgesic (monitor RR)
ACE Inhibitors
--Lisinopril (Prinivil)--
¯ workload of the heart, Helps ¯ mortality rate,
Prevents remodeling of the heart muscle
Side Effects:
- Dry Cough
- Retention of K+- (monitor for ¯ BP)
- Angioedema- (EMERGENCY)
(monitor airway & assess swelling)
Beta Blockers
metoprolol & carvedilol
Thrombolytics (TPA)
Must be given within first 6 hrs to work
Assess pt before
Contraindicated in Pts:
- Major Recent Surgery
- Past Hemorrhagic Stroke
Can also use to de-clot central line
Aspirin
Antiplatelet Agent
Anticoagulants
- heparin & enoxaparin (lovenox)
Assessment
Lungs, Heart, Abdomen, IV site, HR & Rhythm,
Appearance, Chest pain, EKG, Respirations
- Crackles & Edema – notify the physician
Tempernarde- accumulation of fluid in
Pericardial Cavity
Diagnosis
tissue perfusion -
anxiety
Interventions
Help prevent Pulmonary Edema
Need IV Line to Push Meds
Semi-fowlers/fowlers to get oxygen to heart
Oxygen
Vitals Q4H
Active MI- pt needs to be resting until controlled
Invasive Coronary Artery Procedure
--Heart Catheter can be Diagnostic or Interventional---
Gold standard for detecting Stenosis of Coronary Artery
Go thru Femoral Artery & thread all the way to Coronary Artery
- Percutaneous Transluminal Coronary Angioplasty
- Coronary Artery Stent: stent can be coated in meds to help dissolve
clot. After they’ll be on Aspirin or Plavix (1 month to 1 year)
- Atherectomy: Cutting & Shaving off Plague
Coronary Artery Bypass Graft
--Find vein in Leg & Graft to Heart so Blood can Flow--
Pre Procedure--
- Assess allergies
- Get signed consent
- Renal Function bc of Dye
- NPO for 8 hours
- May sign Emergency CAGB
(for if they have MI during Cath Lab
& need emergency surgery)
- Tell pt it can take 2hrs or more
- May have back pain or feel
flushed (dye)
(give analgesics)
Post Procedure--
every 15min x
every 30min x
every 1hour x
Assess:
- site for bleeding
- site should be soft
(hard & painful = hematoma)
- peripheral pulses
- remain flat in bed
- keep affected leg straight
- analgesics for pain
Post Procedure--
- ICU for 1-2 days---then Med Surg
- Pt will have a lot of lines
Assess:
Vitals, Heart/Lung Sound, Heart rhythm LOC, O2 Sat
(big incision on chest & small incisions on legs)
- Assess Pain and control it
Ambulate :
pt needs to be move to chair or ambulate 25-100 ft 48
hrs after to prevent DVT & Atelectasis
(if sx while moving, need to stop & notify someone)
- Deep breathe, Cough and Turn
- Incentive Spirometry – get baseline & use after surgery
- Monitor CBC and BMP
Pre procedure:
- Provide Instruction
- Informed Consent
- Discontinue Meds (anticoagulants, digoxin, diuretics)
Abdominal Aortic Aneurysm
Damaged media layer of the vessel; weakened spot in artery wall; HTN causes bulge in arterial wall
o Genetic
o Age & Gender (Caucasian elderly men 4x more than women)
o Tobacco
o HTN (more than half of people with AAA have HTN)
o Atherosclerosis (most common cause)
o Usually None
o Can feel their heart beating in their abdomen-- May be able to hear a bruit
o Usually picked up with imaging for other things
§ If small, monitor every 6 months to make sure it’s not growing too much
o Meds: control BP with oral medication
o Surgical intervention: if bigger than 2 in or 5 cm, needs surgical intervention (when it reaches 5.5 cm)
§ Open Surgical Repair: open incision & sew stent in place; incision in abdomen
§ Endovascular grafting: like heart cath, go in through groin area and place stent
Pre-Op:
- Maintain Systolic BP 100-120 by giving Anti-hypertensives
- Impending Rupture Signs:
Severe Back & Constant Abdominal Pain (big clue)
- Drop in BP, decreased HCT
- Get baseline vitals & detect peripheral pulses
Post-Op:
- Get baseline vitals
- Vitals Q15min x 4, Q30min x 4 and then every hour
- Assess incision site (no bleeding/hematoma)
- Ensure adequate nutrition
- Assess pain, color and temperature of legs,
peripheral pulses, I/O and volume status
Heart Failure
- can result from HTN and CAD
LEFT SIDED HF RIGHT SIDED HF
Backs up to the Lungs
Backs up to the Rest of Body
(Peripheral & Visceral Organs)
- Dyspnea – (sit pt in HIGH Fowlers)
- Low O2 sats – (may need O2)
- S3 Heart Sound – (bc large volume of fluid entering ventricles)
- Altered Mental Status-- (bc less blood flow to brain)
- Pulmonary Crackle
- Cough, frothy sputum
- Altered mental status
- Fatigue
• JVD
- Edema – (weight gain )
- Ascites
- Hepatomegaly
- Anorexia
- Nausea
- Weakness
Medications for Heart Failure
Digoxin
¯ HR -- by Contraction of Myocardium & ¯ Work Load
(Digoxin Ejection Fraction)
Nursing Care
(Apical < 6 0 --hold)
(-K+ < 3.5---- hold)
- Tell Teleroom you’re pushing
Digoxin bc it will ¯ HR
Early Signs of Toxicity
GI Manifestations/ HR Abnormalities/Visual Disturbances
(diplopia, blurred vision, photophobia, yellow/green halos)
Side Effects
- Anorexia, N&V, Diarrhea
- Drowsiness, Fatigue, Weakness
- Headache
- Depression
- Bradycardia, Dysrhythmias
- Visual Disturbances
ACE Inhibitors
Lisinopril
Beta Blockers
Metoprolol
ARBs
Valsarten
Hydralazine & Isosorbide Dinitrate
Vasodilator
Diuretics
Furosemide
Ca Channel Blocker
Amlodipine & Diltiazem
Antidote: Digibind Therapeutic Range: 0.8 - 2.
Diagnostics
BNP
Hormone that regulates
Volume & BP
Key Diagnostic Indicator in HF
Normal: 0 - 100pg/mL
HF Pts: around 1000 pg/mL
ECG
Ejection Fraction- % of blood being
pumped out
Normal: 55-65%
HF Patients: around 10%
Procedure:
- Takes about 1 hour
- Lie very still on Left side
Lifestyle Recommendations
Sodium Restriction: (2-3g/day)
Fluid Restriction: (1500ml-2L/day)
Daily Weight
- every day at the same time/same clothes
Should be Concerned:
